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Associate Professor of Anesthesiology, Division of Cardio-Thoracic Anesthesia, Adjunct Associate Professor of Medicine, University of Washington, Seattle, WA
To the Editor:
I read with interest, but also with concern, the article by Aronson et al. regarding the development of a certifying examination in perioperative transesophageal echocardiography (1). Although the depth of knowledge required to pass is exhaustive, it is disturbing that there was a 56% pass rate for the 54 candidates who listed the number of exams performed per week as "None." This group probably includes individuals that have entered a practice without TEE, but probably also includes individuals who have taken the exam without hands on experience or training, as is currently allowed. To my mind this is a significant flaw in the system. Clearly, one would not certify someone in any medical specialty if they had not completed practical training, as well as passing a written examination.
I believe that this is an important consideration, as individuals who pass the perioperative examination are often considered qualified to perform and interpret intraoperative TEE. Perhaps the time has come to restrict the exam to those who have completed a period of practical training, or who have long practiced in the field ("grandfather").
Reference
Professor and Director, Cardiothoracic Anesthesia, Department of Anesthesia and Critical Care, Chicago, IL
In Response:
We thank Dr. Oxorn for his interest and comments regarding our article (1). We accept his concerns as important and recognize that approximately 2.5% of people who took and passed the examination may not have had hands-on experience or currently do not actively participate in TEE examinations. In the balance, we are not surprised as this phenomenon is often observed in examinations that test fund of knowledge. Although the rationalization and historic perioperative for training and certification in perioperative TEE are described elsewhere (2), the objectives for the examination include: 1) providing practicing physicians with an opportunity to document a level of proficiency in perioperative TEE that can be measured with an objective standard, 2) providing a method to acknowledge individuals who have achieved a fund of knowledge proficiency that could be applied to overall skills in TEE, and 3) stimulating continuing education and identifying the strengths and weaknesses of training.
We described here the process of developing the examination and believe the objectives were met. The biographic data demonstrated a positive relationship between performance with length of training and number of examinations performed. We acknowledge the examination is not perfect and have pointed out that it continues to be modified based on review of item discrimination, parametric measurement criteria, and periodic performance evaluations.
How or if the examination is considered in the process to establish qualifications to perform and interpret TEE is a matter for hospital credentialing committees. Recently, the SCA and ASE have published recommended guidelines for training in intraoperative TEE (3). These recommendations may also be considered by credentialing committees for intraoperative TEE privileges. Ultimately, however, this decision and the methods for granting privileges will always remain with the hospital credentialing committee. The examination itself (like any examination) is a tool that serves many purposes and we disagree that it should be restricted to otherwise qualified licensed physicians.
References
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